Nursing Elites

1. In the Gram Stain procedure, which component acts as the mordant?

• A. Crystal violet
• B. Methyl alcohol
• C. Iodine
• D. Safranin

Correct answer: C

Rationale: In the Gram Stain procedure, the mordant is Gram's Iodine. The purpose of the mordant is to form a complex with the crystal violet, enhancing its ability to bind to the cell wall. Crystal violet is actually the primary stain used in the Gram Stain procedure to initially color all cells. Methyl alcohol is the decolorizer that removes the crystal violet from certain cell types. Safranin is the counterstain used to stain those cells that did not retain the crystal violet stain after the decolorization step.

2. During a heritage assessment, which question is most appropriate for the nurse to ask?

• A. "Do you smoke?"?
• B. "What is your religion?"?
• C. "Do you have a history of heart disease?"?
• D. "How many years have you lived in the United States?"?

Correct answer: D

Rationale: During a heritage assessment, it is crucial for the nurse to ask questions related to a person's country of ancestry, years in the United States, cultural practices, beliefs, and values. By asking about the number of years lived in the United States, the nurse can gain insights into the individual's cultural background and heritage. Options B, C, and A are not directly related to assessing heritage. Asking about religion only addresses one aspect of heritage, while smoking history and health history do not provide a comprehensive view of a person's heritage.

3. A healthcare professional realizes after a patient has left the office that they forgot to document the patient's complaint of a sore throat. Which of the following choices would BEST correct the error?

• A. Pull out that page of the chart and rewrite it with the correct information.
• B. Put one line through the original Chief Complaint, write 'ERROR,' your initials, and today's date. Make the correction by rewriting the Chief Complaint with the correct information.
• C. Go to the next available line of the SOAP notes. Write the current date, then write 'Late Entry.' Place the date and time when the patient stated they had a sore throat. Sign and date the entry.
• D. All of the above are incorrect.

Correct answer: C

Rationale: When adding information to a patient's chart after the encounter, using the term 'Late Entry' is essential. This clearly indicates that the information was added after the fact and helps to maintain the accuracy and integrity of the medical record. Option A is incorrect because removing a page from the chart and rewriting it can lead to inaccuracies and is not a recommended practice for correcting errors. Option B suggests marking the original Chief Complaint as an error, which may not be clear to future readers of the chart and could lead to confusion. Option D is incorrect as it dismisses the correct approach outlined in Option C, which is the best way to handle the situation of missed documentation during a patient encounter.

4. A urine pregnancy test:

• A. May be negative even if a blood pregnancy test is positive.
• B. Is positive only during the first trimester of pregnancy.
• C. Will be negative if the amount of LH isn't enough to meet or exceed the sensitivity of the testing device.
• D. All of the above.

Correct answer: A

Rationale: A urine pregnancy test detects HCG in a pregnant woman's urine. Blood levels of HCG are usually higher and register earlier than HCG levels in the urine. Choice A is correct because urine pregnancy tests may be negative even if a blood pregnancy test is positive due to the differences in HCG levels in blood and urine. Choice B is incorrect because a urine pregnancy test can be positive throughout pregnancy, not just in the first trimester. Choice C is incorrect because LH (luteinizing hormone) is not the hormone detected in a pregnancy test; it is HCG (human chorionic gonadotropin). Choice D is incorrect because not all the statements provided are true.

5. A client has just started a transfusion of packed red blood cells that a physician ordered. Which of the following signs may indicate a transfusion reaction?

• A. The client suddenly complains of back pain and has chills
• B. The client develops dependent edema in the extremities
• C. The client has a seizure
• D. The client's heart rate drops to 60 bpm

Correct answer: A

Rationale: The correct answer is when the client suddenly complains of back pain and has chills. Signs of a transfusion reaction include back pain, chills, dizziness, increased temperature, and blood in the urine. These signs indicate a possible adverse reaction to the blood transfusion. Dependent edema in the extremities is not typically associated with a transfusion reaction. A seizure is not a common sign of a transfusion reaction unless it is due to severe complications. A decrease in heart rate to 60 bpm is not a typical sign of a transfusion reaction, but rather bradycardia may indicate other underlying conditions or medications.

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